Early Childhood Development for OVC—Key Considerations

Research shows that early childhood development (ECD) is critical to both mental and physical health later in life. However, programming targeting orphans and vulnerable children (OVC) is almost exclusively focused on school-aged OVC, and only rarely are very young children included in program activities. This technical brief, aimed at program planners and implementers, highlights the benefits of ECD interventions and outlines essential elements of ECD programming targeted towards OVC.

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Introduction

Approximately 16.6 million children (under 17 years of age) have lost their parents due to HIV, according to 2009 data (Joint U.N. Programme on HIV/AIDS [UNAIDS] 2010). Millions more children are vulnerable to the physical, psychological, and economic effects of HIV within their households or communities (Joint Learning Initiative on Children and HIV/AIDS 2009). While the systematic study of such orphans and vulnerable children (OVC) is relatively new (Cluver and Operario 2008), observational studies indicate that OVC generally suffer from poor health and nutrition, limited educational and vocational opportunities, developmental delays, and inadequate social and emotional support. These children may also experience more abuse, exploitation, and discrimination than non-OVC.

BOX 1: Early Childhood Development

Rapid advances in biological and behavioral research show early childhood as a time of tremendous brain growth. It is during a child's first few years that the neural connections that shape physical, social, cognitive, and emotional competence develop most rapidly and show the greatest ability to adapt and change. Connections and abilities formed in early childhood form the foundation of subsequent development. As a result, providing the right conditions for healthy early development is likely to be much more effective than treating problems later in life (Center on the Developing Child 2007).

Just as strong foundations provide the basis for positive and healthy adaptations, weak foundations create physiological disruptions that can undermine subsequent learning, behavior, and lifelong physical and mental health. This biological evidence explains how, in the absence of nurturing and supportive relationships—the type of environment in which many OVCs live— adversity can create "toxic stress" that undermines all aspects of a child's subsequent development, creating significant, physically based, long-term obstacles to positive outcomes for these children (Center on the Developing Child 2010; Shonkoff 2010).

Early childhood development (ECD) interventions— those targeting children from birth to age five (and/or age upon entry into school)—are among the most cost-effective approaches for improving outcomes for vulnerable and at-risk children (Cunha and Heckman 2007; Engle et al. 2007). Increasingly robust scientific evidence highlights the critical importance, for better or worse, of ECD on outcomes for children (see Box 1). Recent reviews of ECD programs (Engle et al. 2007; Irwin, Siddiqi, and Hertzman 2007) demonstrate that the benefits of early intervention for all children are far-reaching and lead to reduced instances of stunting, heart disease, and mental illness; increased school attendance; improved social and gender equality; and enhanced prospects for income generation throughout life.

However, there is virtually no research on ECD interventions designed specifically for OVC or for high-prevalence HIV settings. Moreover, OVC programming does not, for the most part, prioritize very young children (Dunn 2005). U.S. Government OVC resources largely focus on school-aged OVC. Though some OVC programs include very young children in their activities, they rarely model their practices on ECD research or best practices. Nor do they distinguish among the profoundly different stages marked by infancy, toddlerhood, preschool, and primary school.

Yet it is possible to design and implement strong, comprehensive ECD programs by focusing on the basic principles of child wellness and development. By incorporating best practices gleaned from worldwide research on ECD in a range of settings, program managers can develop effective OVC programs aimed at very young children. Alternatively, ECD programs and activities can be included within larger initiatives, such as those targeting education, safe motherhood, or family economic support.

This technical brief gives an overview of critical ECD elements and existing evidence for program managers who are interested in implementing ECD programs, or incorporating ECD elements within existing programs to support OVC. The brief describes the three critical elements of ECD, summarizes key findings from program evaluations and literature on ECD,(1) and answers commonly asked questions about developing ECD programs for OVC. It also includes examples of promising ECD interventions that either target or offer relevant models for OVC programs, as well as references to useful resources for learning more about ECD for OVC.(2)

 

Disclaimer: The author's views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

 

1 Searches included PubMed, the Education Resources Information Center, the Cumulative Index to Nursing and Allied Health Literature, and PsycINFO, using various subject terms and keywords, including "child development," "early childhood development," "early childhood education," "HIV," "AIDS," "orphans," "OVC," and "vulnerable children," as well as topical areas such as economic strengthening and child protection.

2 Resources were chosen based on a review of existing resources, including tools and guidelines, as well as via soliciting recommendations from ECD/ OVC practitioners. Program examples were chosen based on a review of existing program documentation, looking at programs that already included OVC components and others that did not have an explicit OVC-related component but worked with vulnerable infants, children, and their families in some capacity, in order to find programs that could offer lessons to OVC-oriented ECD initiatives.

Why Focus on Early Childhood?

According to the Center on the Developing Child, "the future of any society depends on its ability to foster the health and well-being of the next generation" (2007). Ensuring a strong start for OVC is especially important in societies facing high levels of HIV infection, where illness and death erode the ability of the adult generation to nurture children.

ECD Pie Chart


Figure 1. Average Breakdown by Age of OVC Reached by OVC Track 1.0 Programs

Emerging scientific evidence shows that such nurturing is especially critical—though often neglected—for very young OVC (see Box 2 for definitions used in this brief). An expanding body of evidence highlights the importance and potential long-term benefit of early intervention. Studies in such fields as neurology, biology, and behavioral sciences clearly demonstrate that the child's first few years, a time of rapid brain growth that in fact begins before birth, form the foundation of subsequent physical, social, cognitive, emotional, and social development. Importantly, both brain architecture and developing abilities are built "from the bottom up," with simple circuits and skills providing the basis for more advanced circuits and skills over time (Center on the Developing Child 2010; Shonkoff 2010).

The critical factors in optimal ECD care are a safe environment, proper nutrition and medical care, and most importantly, the consistent presence of stable, caring adults (Center on the Developing Child 2010; Shonkoff 2010). OVC, by contrast, often face chronically negative conditions such as inadequate nutrition, unstable relationships with guardians or caregivers, unsafe environments, and lack of opportunities to learn and socialize. In very young children, difficult environments and lack of care and nourishment can lead to physiological damages—" toxic stress"—with potentially lifelong consequences both for children and communities. Toxic stress affects the whole organism, including development of the body's stress response systems, the architecture of the developing brain, the cardiovascular system, and the immune system (National Scientific Council on the Developing Child 2006). OVC are at particular risk during early childhood and, over time, these risk factors are likely to continue to interfere with the developmental processes necessary for positive adaptations in learning, behavior, and health.

BOX 2: Essential Definitions

Early childhood development refers to "the processes by which [infants and young] children grow and thrive, physically, socially, emotionally, and cognitively, during this time period" (U.N. Children's Fund [UNICEF] and Department of Social Development, Republic of South Africa 2006).

Early childhood generally refers to children between birth and the official start of formal schooling. Researchers and organizations also often include the early primary school years— ages six to eight—because of the importance for children of the transition into primary school (Consultative Group on Early Childhood Care and Development 2011).

Orphans and vulnerable children as defined by UNAIDS, and reiterated by the Act that reauthorized the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), are "Children who have lost a parent to HIV/AIDS, who are otherwise directly affected by the disease, or who live in areas of high HIV prevalence and may be vulnerable to the disease or its socioeconomic effects" (Lantos and Hyde 2008, 2). The international community defines children as individuals from birth up to 18 years of age.

Guardian refers to a child's primary caretakers (e.g., parents, grandparents, siblings, extended family members, or foster families).

Caregiver refers to secondary adults involved in the life of OVC (e.g., staff in an ECD center or home-based care providers).

Moreover, the potential benefits of ECD interventions extend beyond survival and health. Early education, for example, can also contribute to the economic and social empowerment of women—in part by improving school success, which keeps girls in school longer, and by extending the age at which women marry and have their first children, which lowers fertility rates (Garcia, Pence, and Evans 2008). This in turn increases the health, education, and well-being of their children. Conversely, a range of family-centered interventions can benefit ECD. For example, ensuring that mothers receive good prenatal care, adequate nutrition, and proper counseling protects the mother-baby pair and contributes to positive ECD outcomes.

However, the U.S. Agency for International Development's (USAID's) U.S. President's Emergency Plan for AIDS Relief (PEPFAR) funded OVC programs have so far devoted limited resources to the youngest children, including ECD initiatives. The OVC Track 1.0 program of PEPFAR is a centrally funded USAID initiative aimed in part to help rapidly scale-up support to OVC affected by HIV in focus countries. An October 2008 evaluation of the program found that the lack of attention to parity across ages resulted in a focus on primary school children, at the cost of children under 5 years and sometimes of children over 12 years (see Figure 1; PEPFAR 2008).

Yet as previously noted, there are good reasons for increasing investment in ECD programming for OVC. Engaging in contextually appropriate, evidence-based, comprehensive interventions during early childhood— interventions that focus on children's relationships, environments, and health—can help ensure a better future for all children, and especially OVC and those affected by HIV.

OVC program managers interested in developing interventions to support ECD should focus on three essential elements in the lives of a very young child:

  • A stable and responsive environment of relationships, which provides young children with consistent, nurturing, and protective interactions with adults, enhances their ability to learn, and helps them develop adaptive capacities
  • A safe and supportive physical environment, which provides places for children that are free from toxins (including chemicals, dirty water, and poor sanitation) and fear and allows active and safe exploration
  • Sound nutrition and disease prevention, which includes immunization and health-promoting levels of food intake, beginning with the mother's health even before conception.

The next section describes these elements in more detail.

Critical Elements of Early Childhood Development Interventions

OVC

Program managers interested in implementing ECD programs, or incorporating ECD elements within existing programs to support OVC, should ensure that activities address these three essential principles of child development.

Stable and Responsive Environment of Relationships

A child's "environment of relationships" refers to the day-to-day interactions between the child and the people in the child's world. This includes family members or caretakers in the home or institutional setting, as well as the people who interact more broadly with children, such as individuals and groups within a community, in school, and in health facilities (Shonkoff 2010).

A large body of research documents that loving, supportive care and secure attachments are critically important for positive child development. The consistent presence of stable, caring adults is one of the most, if not the most, important protective factor in mitigating toxic stress of the kind that many OVC face (Center on the Developing Child 2010; Shonkoff 2010). All children require these types of relationships if they are to acquire the social and cognitive skills that they will use throughout their lives (National Scientific Council on the Developing Child 2004; Thompson 1999, 2000).

Additionally, positive care and support can alleviate some of the deleterious effects of trauma and grief and support the development, or recovery, of well-being and self-esteem, in par t by protecting young OVC from stigma and social isolation. Consistent care can also support good nutrition: research suggests that undereating (and potential malnutrition) may be related to interruptions in care or lack of secure attachments with a guardian (World Health Organization 2004). Program managers interested in implementing ECD programs for OVC should keep this principle in mind: the guardian is the most critical influence in a child's life, and the home and family environment have a major impact on young children's cognitive development and socioemotional well-being (Consultative Group on Early Childhood Care and Development 2007).

Unfortunately, guardians may be unable to provide secure attachments and may be emotionally distant for any number of reasons. Their attention may be occupied by caring for a child living with HIV; they themselves may be living with HIV and unwell; they may be coping with severe poverty; they may suffer from mental health issues or depression triggered by illness or loss; or they may be living with toxic stress themselves. Local childrearing beliefs and caregiving practices may also preclude close relationships with guardians. The social stigma attached to HIV may cause them to reject the child, or they may underestimate the critical role that stimulation plays in ECD (Hudson 2009; Rochat, Mitchell, and Richter 2008; Sherr 2005).

There are a number of interventions that programs can use to strengthen the home and family environment. Home visits, for example, can help children by helping their parents. Home visitors can educate guardians, build their parenting skills, and enhance their psychological well-being by providing training, encouragement, and ongoing support and supervision on how to provide loving and nurturing care and support for a young child (National Scientific Council on the Developing Child 2004). Home visits also provide the chance to work with the whole family and to provide individualized assistance.

Outside the home and family environment, programs need to identify and strengthen the skills and knowledge of the person(s) with whom the young child regularly interacts. Programs can provide training to strengthen the care and stable attachments offered, for example, by caregivers, teachers, and providers of health care and other services, as well other important people or groups that comprise a young child's world. Center-based staff might be trained on the importance of both supportive behavior for caregivers, such as eye-to-eye contact and a close guardian-child bond, and coping strategies for the children, such as giving children a doll or toy to hold or talk to. Other training programs can empower both parents and non-family members to improve their support of vulnerable children (see Box 3 and "Resources").

Safe and Supportive Physical Environments

The survival of any child depends on a healthy environment with access to basic health and other social services, as well as community services and resources that can provide protection and mitigate risks and challenges.

Environmental safety. Safety includes both a child's physical and social surroundings. Physical safety requires protection from environmental risks—for instance, from unsafe water. Around 2.4 million deaths worldwide could likely be prevented each year with correct hygiene practices and the availability of safe, reliable sanitary environments and drinking water. These deaths occur mostly in children in developing countries, as a result of diarrhea and subsequent malnutrition, as well as various other diseases attributable to malnutrition (Bartram and Cairncross 2010). ECD programs can address water and sanitation in a number of ways. For example, center-based programs can provide piped water to the facility or yard, using public taps, safe wells, or collected rainwater, while also educating guardians of the children about the basics of good sanitation and hygiene practices. A good starting place is with various water, hygiene and sanitation (WASH) resources, including the Hygiene Improvement Project's WASH-HIV Integration Toolkit (online at www.hip.watsan.net/page/4489) and AIDSTAR-One's Improving the Lives of People Living with HIV through WASH: Water Sanitation and Hygiene (online at www.aidstar-one.com/focus_areas/care_and_support/WASH).

Social safety. Child protection refers to measures and structures to prevent and respond to abuse, neglect, exploitation, and violence affecting children (Save the Children n.d.). Any child can face abuse, neglect, exploitation, or violence. However, very young children may be particularly vulnerable to abuse, neglect, exploitation, or violence because they are dependent on others for their care and are less able to speak out for themselves than older children (World Health Organization/ International Society for Prevention of Child Abuse and Neglect 2006). Environmental and social factors may exacerbate the potential for breaches of protection for young OVC. For example, overburdened guardians may be unable to supervise children and keep them safe in such environments.

BOX 3: Promising Approach- Training Parents and Caregivers

Hands to Hearts International's (HHI) program provides tools and resources for organizations and caregivers to improve the early development of OVC, including those in orphanages, refugee camps, and severely impoverished or conflict-ridden communities. HHI focuses on empowering direct guardians and caregivers of children in the earliest age range: birth to five years. Through HHI's support and training, caregivers improve their ability to nurture a child's language, social, cognitive, and physical development, as well as their nutrition and overall health, all while cultivating attachment and bonding, which establishes the base for all future relationships.

The training teaches parents, teachers, and other caregivers how their direct and daily actions to nurture and care for a child can improve the child's health, development, and learning potential. HHI's curriculum is age-appropriate and culturally adaptable, and can be used anywhere in the world. While using the curriculum, HHI adapts it with infusions of local knowledge, stories, games, songs, and dances. This empowers people to provide for their children, regardless of their own limited resources, or even the caregiver's own level of literacy. For more information, see www.handstohearts.org.

ECD programs can provide networks of contact and support for guardians and their children. For example, home visits can help identify and refer a child who appears to be at risk, or a family that needs parenting interventions, to specialized support (where such service exists). ECD centers can provide safe spaces where OVC can learn basic life skills, receive the stimulation they need, build their resilience to trauma, and develop in healthy ways.

Evidence suggests that OVC experience reduced school enrollment and attendance—and higher rates of dropout—due to a variety of factors, including poverty, discrimination, and needing to become caretakers themselves (Cluver and Operario 2008). Moreover, children living with HIV often experience developmental delays and may have limited language skills, health problems, and emotional problems that interfere with learning, and so may need extra attention and support. Also, young children who have not attended any type of early education program may not be adequately prepared to learn in a classroom environment when they enter primary school.

By contrast, ECD interventions can enhance school readiness, and improve enrollment in and completion of school (Young and Mustard 2008). These benefits include increased lifetime learning and earning (Lusk and O'Gara 2002). Strong early education programs are age-appropriate, advance literacy and numeracy, and teach the social and emotional skills necessary for cooperating with others. They also address an often neglected but critical aspect of early education and development programs: the opportunity to play. By giving children a way to enact and contemplate specific situations, play creates a strong foundation for the development of emotional organization, representational language, social skills, and other cognitive systems (Bernard van Leer Foundation 2007).

Sound Nutrition and Disease Prevention

Food and Nutrition Security

Malnutrition is among the gravest risks to ECD (Hudson 2009). A large body of research shows that adequate nutrition is necessary for young children to achieve their potential level of cognitive functioning and overall well-being (Engle et al. 2007; Grantham-McGregor et al. 2007; Shonkoff and Phillips 2000). More than half of child deaths worldwide are attributed to malnutrition, and an estimated one-third of children younger than five years old in developing countries suffer from chronic malnutrition, or stunting (low height-for-age), either from lack of food or infection (Walker et al. 2007). Children are most at risk for malnutrition during the prenatal and infancy periods (Shrimpton 2003).

One of the most significant challenges in OVC programs is ensuring access to a diverse and nutritious diet, especially in high HIV-prevalence contexts. As caregivers become ill or die, the household labor supply is diminished, dramatically affecting income and/or the ability cultivate land. Access to nutritious foods is reduced and families often resort to harmful coping strategies (e.g. selling off productive assets, taking children out of school to earn income, migrating to cities, etc.) in order to survive. Complicating this scenario further, those individuals living with HIV (both adults and children) have higher energy requirements, particularly during the symptomatic phase of disease progression, and therefore require more, and often specialized, foods. Good nutrition is especially critical as children (and adults) enter the initial stages of antiretroviral therapy; where hunger has been known to undermine the ability to adhere to treatment.

In some cases, nutritional supplements may be necessary, but managers interested in long-term ECD must combine short term assistance with longterm food security and livelihood activities, such as training youth and OVC caregivers in sustainable agricultural methods (e.g. conservation farming, permaculture, and the development of homestead, kitchen and community gardens). Supporting the livelihoods of youth and OVC caregivers, either in the form of agricultural training or business promotion (e.g. vocational training, income generating activities, and/or improved access to financial services), will improve sustained access to food over the long term. Finally, 'positive living' programming, i.e., providing context-specific and lifecycle relevant information to aid in the preparation and consumption of diverse and nutritious diets and healthy lifestyles, is a crucial aspect of ECD in an HIV context.

General Health and Disease Prevention

Destabilizing circumstances such as HIV in a family, migration, war, and poverty can make it difficult for OVC and their families to afford or use health care and other health protection measures (e.g., mosquito nets). Also, if guardians are disabled by illness, lack knowledge about early childhood health issues, or fear poor treatment or negative attitudes toward HIV from health workers, OVC will likely have reduced access to health care.

Thus, one way of supporting ECD for OVC is through interventions to preserve health. Infectious diseases— including but not limited to HIV—are widespread among young children and can have profound effects on development. Research suggests approximately half of HIV infected infants die within the first two years of life. Pediatric follow-up and prophylactic treatment can avert many of these deaths, even without pediatric antiretroviral therapy (ART), but few children who are HIV-positive have access to such care (Little et al. 2007). Improved roll-out of ART will change the current environment, but until then young children remain in desperate need of access to treatment.

Managers may also find opportunities to provide the most critical elements of care by addressing adult health issues and improving the health of guardians (Carter, Neville, and Newton 2003). For example, the death of a mother from HIV, or another infectious disease, deprives an infant of maternal care as well as access to breastfeeding, which contributes to early immunity. In fact, the mother's health has a direct correlation to a child's overall well-being; yet too often, OVC programs overlook the enormous importance of the prenatal period for ECD. Pregnant women and infants need nutritional support, including micronutrient supplementation, to maintain their own strength and safeguard the health of their unborn infants; in resource-limited areas, both mothers and newborns should also receive nutritional support. Similarly, prevention of mother-to-child transmission (PMTCT) is rarely discussed as an ECD intervention, but providing broad access to PMTCT could save millions of lives and reduce the number of children made vulnerable.

Common Questions About Early Childhood Development Within Orphans and Vulnerable Children Programs

OVC

The following section briefly addresses common questions about ECD and OVC programming.

What are "Comprehensive" Early Childhood Development Programs?

Well developed early childhood programs recognize that all areas of children's growth are interdependent, and hence require a comprehensive, holistic approach. Comprehensive ECD programs for OVC should address a number of the U.N. Children's Fund's (UNICEF) recommended strategies for providing protection, care, and support to children affected by HIV and other children facing extreme risk (UNICEF 2007). These include ensuring that all OVC have access to basic services (i.e., housing, health, and education), offering economic and psychosocial support to families caring for young children, and protecting OVC from abuse and exploitation.

What Activities Should Early Childhood Development Programs Implement?

Activities should be developed with community input and tailored to local conditions. There is no "one size fits all" approach to supporting ECD interventions for OVC. One community might prioritize providing basic child care so that guardians can continue to work. Another community might prefer a guardian education program or a child welfare committee that has a focus on young children. Still another community might be concerned with training staff at early childhood care centers to promote safety, early learning, and later school success. Working with community priorities is fundamental to ensuring the success of a program, but all ECD interventions must also address the core concepts of child development and evidence-based best practice interventions. In some instances, education and sensitization may be needed to help communities better understand the rationale and principles of high-quality ECD programs.

Young children's needs also vary from one setting to another. Program managers should consider social norms and expectations (e.g., the ages for weaning or school entry) along with specific developmental considerations. Also crucial are factors such as gender norms and roles, household economic circumstances, and the broader social landscape.

BOX 4: World Bank Getting Started Checklist

The following are some questions to ask before initiating an ECD program.

  • Can I explain and discuss what is meant by "early childhood," "child care," and "child development"?
  • Can I explain the program implications of the definitions adopted?
  • Can I explain to a skeptical colleague why it is worthwhile to invest in ECD?
  • Do I know the basic approaches to ECD, and which interventions are complementary?
  • Can I make intelligent suggestions about programs and understand where projects or components fit into the larger health and education picture?
  • Have I obtained information about the status of children in the country:

      --Survival, health, and nutrition
      --Cognitive, psychosocial, and emotional child development
      --Progress and performance in primary school.

  • Have I obtained information about childrearing practices in the country?
  • Have I obtained information about the economic, social, cultural, demographic, and political context?
  • Have I identified projects in the country that should be coordinated with an ECD project or attached as a subproject?
  • Have I checked with other child and ECD organizations to find out what ECD activities they are supporting in the country and what people and organizations might be available there for consultancies?
  • Does a national plan of action for children exist? Have relevant social policy statements been identified?
  • Have relevant stakeholders been identified and consulted in order to locate levels of interest, different perceptions of problems, and possible conflicts?
  • Has an institutional analysis been carried out? What resources are available or lacking?
  • Has a central problem been identified and agreed on?
  • Has a project objective been formulated and agreed on that is clearly stated and associated with indicators (of quantity, quality, and time) that can be used to assess its attainment?
  • Have the project approach and the project outputs/activities been agreed on that are clearly stated and associated with indicators (of quantity, quality, and time) that can be used to assess attainment? (Sourced directly from the World Bank, 2011)

One promising example promoting comprehensive care is CARE's 5x5 Model—currently operating in Kenya, Uganda, Rwanda, Zambia, and South Africa— which sets forth five areas of impact: 1) food and nutrition; 2) child development, including physical (gross and fine motor), cognitive (language and sensory), and socioemotional (psychological and emotional); 3) economic strengthening; 4) health; and 5) child protection. OVC are the central focus of the 5x5 Model, but the childcare setting—from crèche to formal school—is the entry point for all interventions (CARE 2006). A second target for intervention is the child's guardians and family, with an emphasis on enhancing parenting skills and improving household economic security. Box 4 lists activities managers should take to initiate an ECD program.

Our Program Focuses on Overall Economic Strengthening. Will This Not Automatically Reach Infants and Young Children in the Household?

Strong evidence shows that poverty aggravates families' vulnerability to "shocks" such as HIV infection or other serious illness, civil conflict, and instability in employment (Booysen 2002; Vermaak et al. 2004). Thus economic support is essential to protect the members of vulnerable households. As noted by a recent report on support for families affected by HIV, "family strengthening programmatic activities must unfold alongside or build upon efforts to strengthen families economically" (Chandan and Richter 2009, iv).

It is generally accepted that boosting family assets and cash availability can affect all aspects of young children's lives by improving their access to health care, nutrition, education, shelter, and other basic services (Consultative Group on Early Childhood Care and Development 2007; UNICEF and Department of Social Development, Republic of South Africa 2006; Zaveri 2008). There is also evidence from Latin America and countries with social welfare sectors—such as South Africa—that regular and predictable monthly child care grants lead to improved levels of nutrition and developmental indicators in all children.

However, targeting the whole family will not necessarily improve the well-being of all children in a particular household. Very young children, in particular, may be overlooked. Managers of programs to strengthen families should be aware of the needs of the youngest children and should consider implementing interventions, or adding activities to existing interventions, to specifically address the special needs of infants and young children and their guardians. This might include providing daycare for women engaged in incomegenerating activities or providing health and parenting information on how to care for the youngest children alongside microfinancing.

How Do We Know Which Infants and Young Children to Target?

An important first step is doing an environmental scan to see which other programs are already targeting guardians and young children, and exploring possible linkages to these programs (see Box 4). For example, collaborations with PMTCT programs offer a tremendous (and often missed) opportunity to support mother-and-child health by providing ECD interventions from the prenatal period on, including more efforts to link facility- and community-based services.

We know that many of the most vulnerable infants and young children are the hardest to reach; they are usually kept in the home, not in institutional settings. This underscores the need to reach households and guardians through home visits or via linkages with health facilities where the guardians of young children visit, and not just via schools or centers. Programs for older children can partner with schools, as schooling is a developed institution in almost all countries, but ECD programs have no equivalent institutions with which to partner.

Members of the community can help to determine eligibility for ECD programs based on local definitions of vulnerability. The Academy for Educational Development's Speak for the Child program in Kenya, for example, identified the most vulnerable young children using a targeting survey based on community criteria for vulnerability. They also developed a number of other targeting strategies that met community approval (e.g., clustering areas by household or choosing the same number of households from neighboring villages; Lusk et al. 2003).

When possible, include all local children in program activities, while recognizing the special developmental needs of OVC, including those affected by HIV. This approach can help remove the stigma that exists within communities and even among service providers. It also aligns with PEPFAR's new strategy, which endorses the principle of being "HIV-sensitive" rather than "HIV-specific" so as to reach the full range of vulnerable children.

We Know That Child Participation in Program Design and Implementation is Important. How Can We Involve Very Young Children in the Process?

Developmentally appropriate methods of communication show children that they are valued and allow them to participate in decisions regarding their own lives. While young children are not able to verbalize their feelings as effectively as older children, and do not understand abstract concepts as older children do, programs can use various methods to engage them and to understand their thoughts and feelings. These include activities such as structured play with dolls, drawing, mapping, and—for children who have some communicative competence (aged three to four years and older)—sharing simple stories about their lives. Such communication can encourage children to express themselves, even on difficult subjects such as HIV, illness, and death. Programs can use the information that children show and tell to understand their desires, fears, and needs (Fanelli and Mushunje 2007; Dunn 2005).

How Do We Know if Our Programs are Working?

Strong programs work toward specific outcomes for children and families, and look for ways to continuously assess their effectiveness in producing these outcomes on an ongoing basis. Programs also need to regularly assess the development of young children over time, so as to identify problems early and deal with them effectively (National Scientific Council on the Developing Child 2007). As there is little research on ECD programs for OVC, managers implementing such programs should conduct rigorous monitoring and evaluation (M&E); such documentation in this setting can provide valuable additions to the literature on ECD.

One promising M&E approach entails adapting lists of internationally recognized ECD milestones and intervention strategies, and integrating them within traditional local childrearing practices, cultural beliefs, and evidence-based practices. Guardians and caregivers can then be trained to monitor these developmental milestones and children's general well-being, and program managers can use this information to assess program progress.

Resources (3)

Building Blocks: Psychosocial Support: Resource for Communities Working with Orphans and Vulnerable Children (International HIV/AIDS Alliance).

This briefing note provides practical guidance on meeting the developmental needs of young children affected by HIV and the care and treatment needs of young children living with HIV. Focusing on children younger than eight years of age, it aims to assist local organizations and service providers to strengthen family and community support for these children. It goes into depth on the following seven topics: education, health and nutrition, psychosocial support, social inclusion, economic strengthening, older carers, and young children and HIV. Available here (PDF, 397 KB).



The Center for Early Childhood Mental Health Consultation (CECMHC; Georgetown University).

This center offers a range of training resources. CECMHC products translate researchbased knowledge into practical strategies that can be implemented in Head Start programs across the country. These products include self-assessment tools and web-based, best-practice tutorials that build the skills and capacity of mental health consultants and program administrators, implementation toolkits for each level of the pyramid model (www.challengingbehavior.org/do/pyramid_model.htm), and relaxation techniques to promote staff wellness. More information is available here.



The Center on the Social and Emotional Foundations of Early Learning (CSEFEL).


This center offers extensive training modules for U.S.- based programs that work with children who are showing challenging behavior and/or vulnerabilities in development. The CSEFEL approach has training modules on a variety of topics, including classroom design, relational support, and care and support for infants and toddlers. More information is available here.



Child Status Index (MEASURE Evaluation).


This tool uses basic descriptive statements to help OVC programs better meet the needs of OVC across six domains
(health, nutrition, shelter and care, education, protection, and psychosocial support). Can be found here.



Early Childhood Program Evaluations: A Decision- Maker's Guide (Center on the Developing Children, Harvard University).


This web-only interactive feature from the National Forum on Early Childhood Policy and Programs helps prepare decision makers to be better consumers of evaluation information by posing five key questions that address both the substance
and the practical utility of rigorous evaluation research. Available here.



Early Childhood Resource Pack: Young Child Survival, Growth & Development through Integrated Program (UNICEF).


This resource pack is designed to help program planners and managers understand the basic elements of the best start in life for children and learn effective strategies for achieving them. It is based on successful large-scale programming experiences of UNICEF and its partners worldwide. One of the five modules of the resource pack (Module Three) focuses on the tools and skills necessary for effective programming for young children in the context of their families and communities. Available online here and through UNICEF country offices.



Examining Early Child Development in Low- Income Countries: A Toolkit for the Assessment of Children in the First Five Years of Life (World Bank).


This toolkit provides a resource for researchers from various disciplines who are interested in planning and evaluating interventions focused on the health and development of infants and young children. Available here (PDF, 2.61 MB).



Hands to Hearts International.


This organization provides tools and resources for organizations and caregivers to improve the early development of OVC, including those in orphanages, refugee camps, and severely impoverished or conflict-ridden communities. More information is available here.



Hope and Healing: A Caregiver's Guide to Helping Young Children Affected by Trauma (Rice and Groves).


This is a manual on working with kids who have experienced significant trauma.



How-To Guide: Child Participation in Education Initiatives (Catholic Relief Services/Zimbabwe).


This guide provides an overview of the importance of child participation and provides guidance on how to measure the scope and level of child participation in a project. It also provides examples of how Catholic Relief Services/Zimbabwe partners facilitate child participation in their education initiatives. Available here for download (PDF, 1.06 MB).



Operational Guidelines for Supporting Early Child Development (ECD) in Multi-sectoral HIV/AIDS Programs in Africa (UNICEF).


This provides guidance for incorporating activities directed at infants and young children into HIV programs in Africa. Effective, broad-scale interventions to assure the healthy physical, emotional, and cognitive development of young children are desperately needed in sub- Saharan Africa and must be an essential component of any well-designed, integrated program to prevent and reduce the impact of HIV in Africa. Available in French and English. Available here (PDF, 948 KB).



Parenting Education Toolkit: Resources for working with families to support young children (UNICEF).


This toolkit presents strategies for strengthening families' competencies to ensure their young children's rights to survival, development, protection, and participation, and has examples of programs from over 30 countries. Good parenting programs not only provide families with critical information on care practices, but they also help families develop skills and confidence in their ability to give their children the best start in life. Available online here and through UNICEF country offices.



The Parenting Map (Project Hope).

This resource offers a data collection tool intended to provide caregivers with a quick but comprehensive snapshot of each child's well-being. Available here.



Promising Practices: Promoting Early Childhood Development for OVC in Resource Constrained Settings: The 5x5 Model (CARE, USAID, and Hope for African Children Initiative).

Currently operating in Kenya, Uganda, Rwanda, Zambia, and South Africa, this promising example promoting comprehensive care sets forth five areas of impact: food and nutrition; child development, including physical (gross and fine motor), cognitive (language and sensory), and socioemotional (psychological and emotional); economic strengthening; health; and child protection. Available here (PDF, 1.64 MB).



Say and Play (Project Concern International).


This resource encourages adults to learn about the experiences and views of young children and helps children freely express themselves in their natural ways through pictures, stories, and games. While many child development materials promote children's intellectual and physical development, few give children the opportunity to express their hopes, fears, and experiences. Through Say and Play, children will find a voice and adults will learn to listen and take action to improve the lives of children. For information or to request copies, contact Project Concern International information desk (brakarsh@yoafrica.com) or the author, Dr. Jonathan Brakarsh, at brakarsh@yoafrica.com.



So You Want to Consult with Children? A Toolkit of Good Practice (International Save the Children Alliance).


This toolkit is designed to help governments, international agencies, and nongovernmental organizations create a participatory environment in which children can express their views and take part in policy debates and discussions. Available here. Also available in Spanish and French.

3 Resource descriptions are mostly taken directly from the websites for the materials/organizations listed.

Acknowledgements

The following individuals kindly contributed to this paper by authoring sections, reviewing copy, and/or providing useful contributions: James Cairns, Project Director, Global Children’s Initiative, Center on the Developing Child at Harvard University; Kara Greenblott, Nzinga International; Deborah Hirschland, Senior Consultant and Trainer, Together for Kids Project; Jessica Malkin, Senior Project Manager, Global Children’s Initiative, Center on the Developing Child at Harvard University; Lyn A. Messner, Project Manager, EnCompass LLC; Laura Peterson, Founder and Executive Director, Hands to Hearts International; Martha Vibbert, Director, SPARK Center, Boston Medical Center; and Irene Felsman, Patricia Kariger, and DeeDee Yates, Independent Consultants.

Additional thanks to Gretchen Bachman, Senior Technical Advisor, Orphans and Vulnerable Children PEPFAR OVC TWG Co-chair, Office of HIV/AIDS, USAID; Colette Bottini, Technical Advisor, Orphans and Vulnerable Children, Office of HIV/AIDS, USAID.

Recommended Citation

AIDSTAR-One. 2011. Early Childhood Development for Orphans and Vulnerable Children: Key Considerations. Arlington, VA: USAID’s AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.

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